Publications by authors named "Marvin G Chang"

34 Publications

An examination of gastrointestinal absorption using the acetaminophen absorption test in critically ill patients with COVID-19: A retrospective cohort study.

Nutr Clin Pract 2021 Jun 8. Epub 2021 Jun 8.

Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Objective: Gastrointestinal (GI) dysfunction is prevalent in critically ill patients with coronavirus disease 2019 (COVID-19). The acetaminophen absorption test (AAT) has been previously described as a direct method for assessment of GI function. Our study determines whether the AAT can be used to assess GI function in critically ill COVID-19 patients, compared with traditional measures of GI function.

Design: Retrospective observational study of critically ill patients with COVID-19.

Setting: Three intensive care units at a tertiary care academic medical center.

Patients: Twenty critically ill patients with COVID-19.

Interventions: The results of AAT and traditional measures for assessing GI function were collected and compared.

Measurements And Main Results: Among the study cohort, 55% (11 of 20) of patients had evidence of malabsorption by AAT. Interestingly, all patients with evidence of malabsorption by AAT had clinical evidence of bowel function, as indicated by stool output and low gastric residuals during the prior 24 h. When comparing patients with a detectable acetaminophen level (positive AAT) with those who had undetectable acetaminophen levels (negative AAT), radiologic evidence of ileus was less frequent (20 vs 88%; P = .03), tolerated tube-feed rates were higher (40 vs 10 ml/h; P =.01), and there was a trend toward lower gastric residual volumes (45 vs 830 ml; P =.11).

Conclusion: Malabsorption can occur in critically ill patients with COVID-19 despite commonly used clinical indicators of tube-feeding tolerance. The AAT provides a simple, rapid, and cost-effective mechanism by which enteral function can be efficiently assessed in COVID-19 patients.
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http://dx.doi.org/10.1002/ncp.10687DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8242470PMC
June 2021

Rapid Expansion of the Airway Response Team to Meet the Needs of the COVID-19 Pandemic.

J Healthc Qual 2021 Mar 18. Epub 2021 Mar 18.

Introduction: The COVID-19 pandemic has brought unprecedented numbers of patients with acute respiratory distress to medical centers. Hospital systems require rapid adaptation to respond to the increased demand for airway management while ensuring high quality patient care and provider safety. There is limited literature detailing successful system-level approaches to adapt to the surge of COVID-19 patients requiring airway management.

Methods: A deliberate system-level approach was used to expand a preexisting airway response service. Through a needs analysis (taking into account both existing resources and anticipated demands), we established priorities and solutions for the airway management challenges encountered during the pandemic.

Results: During our COVID-19 surge (March 10, 2020, through May 26, 2020), there were 619 airway consults, and the COVID airway response team (CART) performed 341 intubations. Despite a 4-fold increase in intubations during the surge, there was no increase in cardiac arrests or surgical airways and no documented COVID-19 infections among the CART.

Conclusions: Our system-level approach successfully met the sudden escalation in demand in airway management incurred by the COVID-19 surge. The approach that addressed staffing needs prioritized provider protection and enhanced quality and safety monitoring may be adaptable to other institutions.
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http://dx.doi.org/10.1097/JHQ.0000000000000304DOI Listing
March 2021

An examination of sedation requirements and practices for mechanically ventilated critically ill patients with COVID-19.

Am J Health Syst Pharm 2021 May 16. Epub 2021 May 16.

Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Purpose: Preliminary reports suggest that critically ill patients with coronavirus disease 2019 (COVID-19) infection requiring mechanical ventilation may have markedly increased sedation needs compared with non-mechanically ventilated patients. We conducted a study to examine sedative use for this patient population within multiple intensive care units (ICUs) of a large academic medical center.

Methods: A retrospective, single-center cohort study of sedation practices for critically ill patients with COVID-19 during the first 10 days of mechanical ventilation was conducted in 8 ICUs at Massachusetts General Hospital, Boston, MA. The study population was a sequential cohort of 86 critically ill, mechanically ventilated patients with COVID-19. Data characterizing the sedative medications, doses, drug combinations, and duration of administration were collected daily and compared to published recommendations for sedation of critically ill patients without COVID-19. The associations between drug doses, number of drugs administered, baseline patient characteristics, and inflammatory markers were investigated.

Results: Among the study cohort, propofol and hydromorphone were the most common initial drug combination, with these medications being used on a given day in up to 100% and 88% of patients, respectively. The doses of sedative and analgesic infusions increased for patients over the first 10 days, reaching or exceeding the upper limits of published dosage guidelines for propofol (48% of patients), dexmedetomidine (29%), midazolam (7.7%), ketamine (32%), and hydromorphone (38%). The number of sedative and analgesic agents simultaneously administered increased over time for each patient, with more than 50% of patients requiring 3 or more agents by day 2. Compared with patients requiring 3 or fewer agents, as a group patients requiring more than 3 agents were of younger age, had an increased body mass index, increased serum ferritin and lactate dehydrogenase concentrations, had a lower PaO2:FIO2 (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen), and were more likely to receive neuromuscular blockade.

Conclusion: Our study confirmed the clinical impression of elevated sedative use in critically ill, mechanically ventilated patients with COVID-19 relative to guideline-recommended sedation practices in other critically ill populations.
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http://dx.doi.org/10.1093/ajhp/zxab202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8194529PMC
May 2021

Right Ventricular Strain Is Common in Intubated COVID-19 Patients and Does Not Reflect Severity of Respiratory Illness.

J Intensive Care Med 2021 Aug 30;36(8):900-909. Epub 2021 Mar 30.

Department of Anesthesia, Critical Care, and Pain Medicine, 2348Massachusetts General Hospital, Boston, MA, USA.

Background: Right ventricular (RV) dysfunction is common and associated with worse outcomes in patients with coronavirus disease 2019 (COVID-19). In non-COVID-19 acute respiratory distress syndrome, RV dysfunction develops due to pulmonary hypoxic vasoconstriction, inflammation, and alveolar overdistension or atelectasis. Although similar pathogenic mechanisms may induce RV dysfunction in COVID-19, other COVID-19-specific pathology, such as pulmonary endothelialitis, thrombosis, or myocarditis, may also affect RV function. We quantified RV dysfunction by echocardiographic strain analysis and investigated its correlation with disease severity, ventilatory parameters, biomarkers, and imaging findings in critically ill COVID-19 patients.

Methods: We determined RV free wall longitudinal strain (FWLS) in 32 patients receiving mechanical ventilation for COVID-19-associated respiratory failure. Demographics, comorbid conditions, ventilatory parameters, medications, and laboratory findings were extracted from the medical record. Chest imaging was assessed to determine the severity of lung disease and the presence of pulmonary embolism.

Results: Abnormal FWLS was present in 66% of mechanically ventilated COVID-19 patients and was associated with higher lung compliance (39.6 vs 29.4 mL/cmHO, = 0.016), lower airway plateau pressures (21 vs 24 cmHO, = 0.043), lower tidal volume ventilation (5.74 vs 6.17 cc/kg, = 0.031), and reduced left ventricular function. FWLS correlated negatively with age (r = -0.414, = 0.018) and with serum troponin (r = 0.402, = 0.034). Patients with abnormal RV strain did not exhibit decreased oxygenation or increased disease severity based on inflammatory markers, vasopressor requirements, or chest imaging findings.

Conclusions: RV dysfunction is common among critically ill COVID-19 patients and is not related to abnormal lung mechanics or ventilatory pressures. Instead, patients with abnormal FWLS had more favorable lung compliance. RV dysfunction may be secondary to diffuse intravascular micro- and macro-thrombosis or direct myocardial damage.

Trial Registration: National Institutes of Health #NCT04306393. Registered 10 March 2020, https://clinicaltrials.gov/ct2/show/NCT04306393.
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http://dx.doi.org/10.1177/08850666211006335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8267080PMC
August 2021

Biplane Imaging Using Portable Ultrasound Devices for Vascular Access.

Cureus 2021 Jan 7;13(1):e12561. Epub 2021 Jan 7.

Anesthesiology and Critical Care, Massachusetts General Hospital, Boston, USA.

The use of ultrasound guidance for the placement of difficult IVs, arterial lines, and central venous access has become the standard of care. While imaging quality has improved over the last two decades, the lack of affordability, availability, and training have been major limitations in its routine clinical use. We detail the first reported use of biplane imaging using a portable ultrasound probe for difficult vascular access to increase first past success, efficiency, safety, and sterility during the coronavirus disease 2019 (COVID-19) pandemic.
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http://dx.doi.org/10.7759/cureus.12561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793334PMC
January 2021

Sodium-glucose cotransporter-2 (SGLT2) inhibitor-induced euglycemic diabetic ketoacidosis complicating the perioperative management of a patient with type 2 diabetes mellitus (T2DM) and Fournier's gangrene: A case report.

Int J Surg Case Rep 2020 11;77:463-466. Epub 2020 Nov 11.

Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA.

Introduction: Sodium glucose cotransporter-2 inhibitors (SGLT2) are an increasingly administered class of medication used to lower blood glucose levels in patients with type 2 diabetes mellitus. Diabetic ketoacidosis (DKA) and Fournier's gangrene are rare, but potentially catastrophic side effects of SGLT2 inhibitors. This manuscript reports a case of both DKA and Fournier's gangrene in the context of SGLT2 inhibitor use.

Presentation Of Case: A 51-year-old morbidly obese man with hypertension and poorly controlled Type 2 Diabetes Mellitus presented to the emergency department with a clinical presentation consistent with Fournier's gangrene. He was promptly taken to the operating room by the urology team where he had extensive debridement of the perineum and abdomen. Intra-operatively he was found to have DKA, which was managed appropriately. The acidosis and Fournier's gangrene were deemed a likely side effect of SGLT2 inhibitor use. After a thirty-day hospital admission, the patient was discharged to a rehabilitation facility where he is progressing well. His SGLT2 inhibitor was discontinued upon admission to hospital.

Discussion: Perioperative providers should have a high index of suspicion for diabetic ketoacidosis (DKA) and Fournier's gangrene in patients prescribed SGLT2 inhibitors. Prompt treatment of DKA through correction of underlying triggers, aggressive fluid resuscitation, insulin to close the anion gap, and appropriate potassium repletion is vital to optimize patient outcomes.

Conclusion: The use of SGLT2 inhibitors among surgical populations is increasing. This case highlights the importance of being aware of the mechanism and side effects of SGLT2 inhibitors, and the management of DKA.
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http://dx.doi.org/10.1016/j.ijscr.2020.11.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695895PMC
November 2020

Ensuring competency in focused cardiac ultrasound: a systematic review of training programs.

J Intensive Care 2020 Dec 11;8(1):93. Epub 2020 Dec 11.

Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA.

Background: Focused cardiac ultrasound (FoCUS) is a valuable skill for rapid assessment of cardiac function and volume status. Despite recent widespread adoption among physicians, there is limited data on the optimal training methods for teaching FoCUS and metrics for determining competency. We conducted a systematic review to gain insight on the optimal training strategies, including type and duration, that would allow physicians to achieve basic competency in FoCUS.

Methods: Embase, PubMed, and Cochrane Library databases were searched from inception to June 2020. Included studies described standardized training programs for at least 5 medical students or physicians on adult FoCUS, followed by an assessment of competency relative to an expert. Data were extracted, and bias was assessed for each study.

Results: Data were extracted from 23 studies on 292 learners. Existing FoCUS training programs remain varied in duration and type of training. Learners achieved near perfect agreement (κ > 0.8) with expert echocardiographers on detecting left ventricular systolic dysfunction and pericardial effusion with 6 h each of didactics and hands-on training. Substantial agreement (κ > 0.6) on could be achieved in half this time.

Conclusion: A short training program will allow most learners to achieve competency in detecting left ventricular systolic dysfunction and pericardial effusion by FoCUS. Additional training is necessary to ensure skill retention, improve efficiency in image acquisition, and detect other pathologies.
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http://dx.doi.org/10.1186/s40560-020-00503-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7730755PMC
December 2020

In Response.

Anesth Analg 2020 11;131(5):e234-e235

Division of Cardiac Anesthesia and Critical Care, Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,

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http://dx.doi.org/10.1213/ANE.0000000000005144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7389936PMC
November 2020

Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management.

Chest 2021 Mar 21;159(3):1155-1165. Epub 2020 Sep 21.

Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA.

Emergency airway management (EAM) is associated with a high rate of complications, morbidity, and mortality. Handheld point-of-care ultrasound shows promise as an emerging technology to facilitate rapid screening for difficult laryngoscopy, identify the cricothyroid membrane for potential cricothyroidotomy, and assess for increased aspiration risk, as well as provide confirmation of proper endotracheal tube positioning. This review summarizes the available evidence for the use of point-of-care ultrasound in EAM, provides an algorithm to facilitate its incorporation into existing EAM practice to improve patient safety, and serves as a framework for future validation studies.
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http://dx.doi.org/10.1016/j.chest.2020.09.083DOI Listing
March 2021

Comparison of published guidelines for management of coagulopathy and thrombosis in critically ill patients with COVID 19: implications for clinical practice and future investigations.

Crit Care 2020 09 16;24(1):559. Epub 2020 Sep 16.

Division of Cardiac Anesthesia and Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA.

Critically ill patients with COVID-19 are at increased risk for thrombotic complications which has led to an intense debate surrounding their anticoagulation management. In the absence of data from randomized controlled clinical trials, a number of consensus guidelines and recommendations have been published to facilitate clinical decision-making on this issue. However, substantive differences exist between these guidelines which can be difficult for clinicians. This review briefly summarizes the major societal guidelines and compares their similarities and differences. A common theme in all of the recommendations is to take an individualized approach to patient management and a call for prospective randomized clinical trials to address important anticoagulation issues in this population.
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http://dx.doi.org/10.1186/s13054-020-03273-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492793PMC
September 2020

Multisystem effects of COVID-19: a concise review for practitioners.

Postgrad Med 2021 Jan 4;133(1):20-27. Epub 2020 Nov 4.

Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital , Boston, MA, USA.

While COVID-19 has primarily been characterized by the respiratory impact of viral pneumonia, it affects every organ system and carries a high consequent risk of death in critically ill patients. Higher sequential organ failure assessment (SOFA) scores have been associated with increased mortality in patients critically ill patients with COVID-19. It is important that clinicians managing critically ill COVID-19 patients be aware of the multisystem impact of the disease so that care can be focused on the prevention of end-organ injuries to potentially improve clinical outcomes. We review the multisystem complications of COVID-19 and associated treatment strategies to improve the care of critically ill COVID-19 patients.
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http://dx.doi.org/10.1080/00325481.2020.1823094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7651182PMC
January 2021

Perioperative TTE Service: Developing a Roadmap for Success.

J Cardiothorac Vasc Anesth 2021 01 29;35(1):233-234. Epub 2020 Jul 29.

Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Electronic address:

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http://dx.doi.org/10.1053/j.jvca.2020.07.072DOI Listing
January 2021

Bedside monitoring of lung perfusion by electrical impedance tomography in the time of COVID-19.

Br J Anaesth 2020 11 7;125(5):e434-e436. Epub 2020 Aug 7.

Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.bja.2020.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413127PMC
November 2020

High Concentrations of Nitric Oxide Inhalation Therapy in Pregnant Patients With Severe Coronavirus Disease 2019 (COVID-19).

Obstet Gynecol 2020 12;136(6):1109-1113

Department of Anesthesia, the Department of Pediatrics, the Respiratory Care Department, the Department of Obstetrics and Gynecology, and the Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts; and the Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama.

Background: Rescue therapies to treat or prevent progression of coronavirus disease 2019 (COVID-19) hypoxic respiratory failure in pregnant patients are lacking.

Method: To treat pregnant patients meeting criteria for severe or critical COVID-19 with high-dose (160-200 ppm) nitric oxide by mask twice daily and report on their clinical response.

Experience: Six pregnant patients were admitted with severe or critical COVID-19 at Massachusetts General Hospital from April to June 2020 and received inhalational nitric oxide therapy. All patients tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A total of 39 treatments was administered. An improvement in cardiopulmonary function was observed after commencing nitric oxide gas, as evidenced by an increase in systemic oxygenation in each administration session among those with evidence of baseline hypoxemia and reduction of tachypnea in all patients in each session. Three patients delivered a total of four neonates during hospitalization. At 28-day follow-up, all three patients were home and their newborns were in good condition. Three of the six patients remain pregnant after hospital discharge. Five patients had two negative test results on nasopharyngeal swab for SARS-CoV-2 within 28 days from admission.

Conclusion: Nitric oxide at 160-200 ppm is easy to use, appears to be well tolerated, and might be of benefit in pregnant patients with COVID-19 with hypoxic respiratory failure.
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http://dx.doi.org/10.1097/AOG.0000000000004128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673637PMC
December 2020

Transthoracic Echocardiography in Prone Patients With Acute Respiratory Distress Syndrome: A Feasibility Study.

Crit Care Explor 2020 Aug 7;2(8):e0179. Epub 2020 Aug 7.

All authors: Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA.

Objectives: Patients with acute respiratory distress syndrome are at risk for developing cardiac dysfunction which is independently associated with worse outcomes. Transthoracic echocardiography is an ideal imaging modality for goal-directed assessment and optimization of cardiac function and volume status. Prone positioning, while demonstrated to improve oxygenation, offload the right ventricle, and reduce short-term mortality in acute respiratory distress syndrome, has previously precluded transthoracic echocardiography on these patients. The purpose of this study was to assess the ability to perform focused transthoracic echocardiography examinations on acute respiratory distress syndrome patients in the prone position.

Design: We performed a cross-sectional study of critically ill patients hospitalized for acute respiratory distress syndrome due to coronavirus disease 2019.

Setting: This study was conducted in medical and surgical intensive units in a tertiary hospital.

Patients: We examined 27 mechanically ventilated and prone patients with acute respiratory distress syndrome due to coronavirus disease 2019. Participants were examined at the time of enrollment in an ongoing clinical trial (NCT04306393), and no patients were excluded from echocardiographic analysis.

Interventions: None.

Measurements And Main Results: We were able to perform transthoracic echocardiography and obtain satisfactory images for quantitative assessment of right ventricular function in 24 out of 27 (88.9%) and left ventricular function in 26 out of 27 (96.3%) of patients in the prone position, including many who were obese and on high levels of positive end-expiratory pressure (≥ 15 cm HO).

Conclusions: Transthoracic echocardiography can be performed at the prone patient's bedside by critical care intensivists. These findings encourage the use of focused transthoracic echocardiography for goal-directed cardiac assessment in acute respiratory distress syndrome patients undergoing prone positioning.
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http://dx.doi.org/10.1097/CCE.0000000000000179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7417147PMC
August 2020

Above and beyond: biofilm and the ongoing search for strategies to reduce ventilator-associated pneumonia (VAP).

Crit Care 2020 08 18;24(1):510. Epub 2020 Aug 18.

Division of Critical Care, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.

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http://dx.doi.org/10.1186/s13054-020-03234-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7432533PMC
August 2020

Ultrasound Teleguidance to Reduce Healthcare Worker Exposure to Coronavirus Disease 2019.

Crit Care Explor 2020 Jun 11;2(6):e0146. Epub 2020 Jun 11.

Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA.

The global spread of coronavirus disease 2019 has accelerated the adoption of technologies that facilitate patient care while reducing viral spread. We illustrate a proof of concept application of teleguidance to ultrasound-guided bedside procedures as an example of an innovative solution that has been used at our institution to maximize patient and provider safety.
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http://dx.doi.org/10.1097/CCE.0000000000000146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314327PMC
June 2020

Rapid establishment of an ICU using anesthesia ventilators during COVID-19 pandemic: lessons learned.

Crit Care 2020 06 30;24(1):388. Epub 2020 Jun 30.

Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1186/s13054-020-03107-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326394PMC
June 2020

Handheld ultrasound devices: An emerging technology to reduce viral spread during the Covid-19 pandemic.

Am J Infect Control 2020 08 5;48(8):968-969. Epub 2020 Jun 5.

Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ajic.2020.05.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273157PMC
August 2020

In-hospital airway management of COVID-19 patients.

Crit Care 2020 06 5;24(1):292. Epub 2020 Jun 5.

Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Those involved in the airway management of COVID-19 patients are particularly at risk. Here, we describe a practical, stepwise protocol for safe in-hospital airway management in patients with suspected or confirmed COVID-19 infection.
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http://dx.doi.org/10.1186/s13054-020-03018-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274058PMC
June 2020

Personal Protective Equipment N95 Facemask Shortage Quick Fix: The Modified Airway From VEntilatoR Circuit (MAVerIC).

Cureus 2020 May 1;12(5):e7914. Epub 2020 May 1.

Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA.

We are in a crisis where healthcare providers on the frontlines are running out of the appropriate personal protective equipment including N95 masks and power air-purifying respirators. Here, we propose a makeshift filter mask that we call the Modified Airway from VEntilatoR Circuit (MAVerIC) that can be assembled within seconds using widely available supplies routinely utilized by anesthesia providers in the operating room to provide practitioners on the frontlines with the high standard of protection of a N95 mask during the coronavirus disease 2019 (COVID-19) pandemic, and can be easily quantitatively "fit tested" to ensure no significant leak to optimize safety and efficacy.
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http://dx.doi.org/10.7759/cureus.7914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237167PMC
May 2020

The Vacuum Assisted Negative Pressure Isolation Hood (VANISH) System: Novel Application of the Stryker Neptune™ Suction Machine to Create COVID-19 Negative Pressure Isolation Environments.

Cureus 2020 May 14;12(5):e8126. Epub 2020 May 14.

Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA.

Coronavirus disease 2019 (COVID-19) may remain viable in the air for up to three hours, placing health care workers in close proximity to aerosolizing procedures particularly at high risk for infection. This combined with the drastic shortage of negative pressure rooms hospitals worldwide has led to the rapid innovation of novel biohazard isolation hoods, which can be adapted to create negative pressure isolation environments around the patient's airway using the hospital wall suction, which carries many limitations, including weaker suction capabilities, single patient use, and immobility. Here, we report our Vacuum Assisted Negative Pressure Isolation Hood (VANISH) system that uses a mobile and readily available in most hospital operating rooms Stryker Neptune™ (Stryker Corporation, Kalamazoo, Michigan) high-powered suction system to more effectively create a negative pressure biohazard isolation environment. VANISH has been utilized regularly in an anesthesia practice of 30+ providers and, to date, there have been no documented COVID-19 infections.
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http://dx.doi.org/10.7759/cureus.8126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228800PMC
May 2020

Nutrition in critically ill patients with COVID-19: Challenges and special considerations.

Clin Nutr 2020 07 15;39(7):2327-2328. Epub 2020 May 15.

Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1016/j.clnu.2020.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227546PMC
July 2020

Application of Lung Ultrasound During the COVID-19 Pandemic: A Narrative Review.

Anesth Analg 2020 08;131(2):345-350

From the Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

This review highlights the ultrasound findings reported from a number of studies and case reports and discusses the unifying findings from coronavirus disease (COVID-19) patients and from the avian (H7N9) and H1N1 influenza epidemics. We discuss the potential role for portable point-of-care ultrasound (PPOCUS) as a safe and effective bedside option in the initial evaluation, management, and monitoring of disease progression in patients with confirmed or suspected COVID-19 infection.
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http://dx.doi.org/10.1213/ANE.0000000000004929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202122PMC
August 2020

ST Elevations and Ventricular Tachycardia Secondary to Coronary Vasospasm upon Extubation.

Case Rep Anesthesiol 2020 12;2020:1527345. Epub 2020 Feb 12.

Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, Massachusetts, USA.

ST elevations (STE) in the perioperative setting can result from a number of different etiologies, the most common and feared being acute coronary syndrome (ACS). However, other causes should be considered, as treatment may differ depending on the diagnosis. Here, we describe a case of STE and ventricular tachycardia in a patient at high risk for ACS. The patient had a prior diagnosis of coronary vasospasm; however, given pre-existing risk factors, much consideration and deliberation occurred prior to electing conservative therapy. This report provides an overview of perioperative vasospasm and other causes of STE, which anesthesiologists should be aware of.
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http://dx.doi.org/10.1155/2020/1527345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7037527PMC
February 2020

Intraoperative Management of Left Ventricular Assist Device Explantation: Complications and Lessons Learned.

J Cardiothorac Vasc Anesth 2020 Apr 17;34(4):1002-1004. Epub 2019 Oct 17.

Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1053/j.jvca.2019.10.022DOI Listing
April 2020

Pro- and antiarrhythmic effects of ATP-sensitive potassium current activation on reentry during early afterdepolarization-mediated arrhythmias.

Heart Rhythm 2013 Apr 12;10(4):575-82. Epub 2012 Dec 12.

Department of Medicine (Cardiology), David Geffen School of Medicine at University of California, Los Angeles, CA 90095, USA.

Background: Under conditions promoting early afterdepolarizations (EADs), ventricular tissue can become bi-excitable, that is, capable of wave propagation mediated by either the Na current (INa) or the L-type calcium current (ICa,L), raising the possibility that ICa,L-mediated reentry may contribute to polymorphic ventricular tachycardia (PVT) and torsades de pointes. ATP-sensitive K current (IKATP) activation suppresses EADs, but the effects on ICa,L-mediated reentry are unknown.

Objective: To investigate the effects of IKATP activation on ICa,L-mediated reentry.

Methods: We performed optical voltage mapping in cultured neonatal rat ventricular myocyte monolayers exposed to BayK8644 and isoproterenol. The effects of pharmacologically activating IKATP with pinacidil were analyzed.

Results: In 13 monolayers with anatomic ICa,L-mediated reentry around a central obstacle, pinacidil (50 μM) converted ICa,L-mediated reentry to INa-mediated reentry. In 33 monolayers with functional ICa,L-mediated reentry (spiral waves), pinacidil terminated reentry in 17, converted reentry into more complex INa-mediated reentry resembling fibrillation in 12, and had no effect in 4. In simulated 2-dimensional bi-excitable tissue in which ICa,L- and INa-mediated wave fronts coexisted, slow IKATP activation (over minutes) reliably terminated rotors but rapid IKATP activation (over seconds) often converted ICa,L-mediated reentry to INa-mediated reentry resembling fibrillation.

Conclusions: IKATP activation can have proarrhythmic effects on EAD-mediated arrhythmias if ICa,L-mediated reentry is present.
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http://dx.doi.org/10.1016/j.hrthm.2012.12.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4285341PMC
April 2013

Dynamics of early afterdepolarization-mediated triggered activity in cardiac monolayers.

Biophys J 2012 Jun 19;102(12):2706-14. Epub 2012 Jun 19.

Cardiovascular Research Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.

Early afterdepolarizations (EADs) are voltage oscillations that occur during the repolarizing phase of the cardiac action potential and cause cardiac arrhythmias in a variety of clinical settings. EADs occur in the setting of reduced repolarization reserve and increased inward-over-outward currents, which intuitively explains the repolarization delay but does not mechanistically explain the time-dependent voltage oscillations that are characteristic of EADs. In a recent theoretical study, we identified a dual Hopf-homoclinic bifurcation as a dynamical mechanism that causes voltage oscillations during EADs, depending on the amplitude and kinetics of the L-type Ca(2+) channel (LTCC) current relative to the repolarizing K(+) currents. Here we demonstrate this mechanism experimentally. We show that cardiac monolayers exposed to the LTCC agonists BayK8644 and isoproterenol produce EAD bursts that are suppressed by the LTCC blocker nitrendipine but not by the Na(+) current blocker tetrodoxin, depletion of intracellular Ca(2+) stores with thapsigargin and caffeine, or buffering of intracellular Ca(2+) with BAPTA-AM. These EAD bursts exhibited a key dynamical signature of the dual Hopf-homoclinic bifurcation mechanism, namely, a gradual slowing in the frequency of oscillations before burst termination. A detailed cardiac action potential model reproduced the experimental observations, and identified intracellular Na(+) accumulation as the likely mechanism for terminating EAD bursts. Our findings in cardiac monolayers provide direct support for the Hopf-homoclinic bifurcation mechanism of EAD-mediated triggered activity, and raise the possibility that this mechanism may also contribute to EAD formation in clinical settings such as long QT syndromes, heart failure, and increased sympathetic output.
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http://dx.doi.org/10.1016/j.bpj.2012.05.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3379011PMC
June 2012

Bi-stable wave propagation and early afterdepolarization-mediated cardiac arrhythmias.

Heart Rhythm 2012 Jan 17;9(1):115-22. Epub 2011 Aug 17.

Department of Medicine (Cardiology), David Geffen School of Medicine at University of California, Los Angeles, California 90095, USA.

Background: In normal atrial and ventricular tissue, the electrical wavefronts are mediated by the fast sodium current (I(Na)), whereas in sinoatrial and atrioventricular nodal tissue, conduction is mediated by the slow L-type calcium current (I(Ca,L)). However, it has not been shown whether the same tissue can exhibit both the I(Na)-mediated and the I(Ca,L)-mediated conduction.

Objective: This study sought to test the hypothesis that bi-stable cardiac wave conduction, mediated by I(Na) and I(Ca,L), respectively, can occur in the same tissue under conditions promoting early afterdepolarizations (EADs), and to study how this novel wave dynamics is related to the mechanisms of EAD-mediated arrhythmias.

Methods: Computer models of two-dimensional (2D) tissue with a physiologically detailed action potential model were used to study the bi-stable wave dynamics. Theoretical predictions were tested experimentally by optical mapping in neonatal rat ventricular myocyte monolayers.

Results: In the same 2D homogeneous tissue, we could induce spiral waves that are mediated by either I(Na) or I(Ca,L) under conditions in which the action potential model exhibited EADs. This bi-stable wave propagation behavior was similar to bi-stability shown in many other nonlinear systems. Because the bi-stable states are also excitable, we call this novel behavior bi-excitability. In a 2D heterogeneous tissue, the I(Ca,L)-mediated spiral wave meanders, giving rise to a twisting electrocardiographic QRS axis, resembling torsades de pointes, whereas the coexistence and interplay between the I(Na)-mediated wavefronts and I(Ca,L)-mediated wavefronts give rise to polymorphic ventricular tachycardia. We also present experimental evidence for bi-excitability under EAD-promoting conditions in neonatal rat ventricular myocyte monolayers exposed to BayK8644 and isoproterenol.

Conclusion: Under EAD-prone conditions, both I(Na)-mediated conduction and I(Ca,L)-mediated conduction can occur in the same tissue. These novel wave dynamics may be responsible for certain EAD-mediated arrhythmias, such as torsades de pointes and polymorphic ventricular tachycardia.
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http://dx.doi.org/10.1016/j.hrthm.2011.08.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246094PMC
January 2012

Atrioventricular conduction and arrhythmias at the initiation of beating in embryonic mouse hearts.

Dev Dyn 2010 Jul;239(7):1941-9

UCLA Cardiovascular Research Laboratory, David Geffen School of Medicine, University of California-Los Angeles, 675 Charles Young Drive South, Los Angeles, CA 90095, USA.

To investigate cardiac physiology at the onset of heart beating in embryonic mouse hearts, we performed optical imaging of membrane potential (Vm) and/or intracellular calcium (Ca(i)). Action potentials and Ca(i) transients were detected in approximately 50% of mouse embryo hearts at E8.5, but in all hearts at E9.0, indicating that beating typically starts between E8-E9. Beating was eliminated by Ca channel blocker nifedipine and the I(f) blocker ZD7288, unaffected by tetrodotoxin and only mildly depressed by disabling sarcoplasmic (SR) and endoplasmic (ER) reticulum Ca cycling. From E8.5 to E10, conduction velocity increased from 0.2-1 mm/s to >5 mm/s in first ventricular and then atrial tissue, while remaining slow in other areas. Arrhythmias included atrioventricular reentry induced by adenosine. In summary, at the onset of beating, I(f)-dependent pacemaking drives both AP propagation and Ca(i) transient generation through activation of voltage-dependent Ca channels. Na channels and intracellular Ca cycling have minor roles.
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http://dx.doi.org/10.1002/dvdy.22319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908293PMC
July 2010
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